Carry on screening: A brief look at Internet Gaming Disorder

In this month’s issue of the Neuropsychiatry journal, I – and my research colleagues (Dr. Daniel King and Dr. Zsolt Demetrovics) – published a paper arguing that Internet Gaming Disorder needs a unified approach to assessment. Over the last 15 years, research into various online addictions has greatly increased. Prior to the publication of the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013, there had been some debate as to whether ‘internet addiction’ should be introduced into the text as a separate disorder. Alongside this, there has also been debate as to whether those researching in the online addiction field should be researching generalized internet use and/or the potentially addictive activities that can be engaged on the internet (e.g., gambling, video gaming, sex, shopping, etc.)

Following these debates, the Substance Use Disorder Work Group (SUDWG) recommended that the DSM-5 include a sub-type of problematic internet use (i.e., internet gaming disorder [IGD]) in Section 3 (‘Emerging Measures and Models’) as an area that needed future research before being included in future editions of the DSM. According to Dr. Nancy Petry and Dr. Charles O’Brien writing in a 2013 issue of Addiction, IGD will not be included as a separate mental disorder until the (i) defining features of IGD have been identified, (ii) reliability and validity of specific IGD criteria have been obtained cross-culturally, (iii) prevalence rates have been determined in representative epidemiological samples across the world, and (iv) etiology and associated biological features have been evaluated.

Although there is now a rapidly growing literature on pathological video gaming, one of the key reasons that IGD was not included in the main text of the DSM-5 was that the SUDWG concluded that no standard diagnostic criteria were used to assess gaming addiction across these many studies. A 2013 overview of instruments assessing problematic gaming by my colleagues and I in Clinical Psychology Review reported that 18 different screening instruments had been developed, and that these had been used in 63 quantitative studies comprising 58,415 participants. This comprehensive review identified both strengths and weaknesses of these instruments.

The main strengths of the instrumentation included the: (i) the brevity and ease of scoring, (ii) excellent psychometric properties such as convergent validity and internal consistency, and (iii) robust data that will aid the development of standardized norms for adolescent populations. However, the main weaknesses identified in the instrumentation included: (i) core addiction indicators being inconsistent across studies, (iii) a general lack of any temporal dimension, (iii) inconsistent cut-off scores relating to clinical status, (iv) poor and/or inadequate inter-rater reliability and predictive validity, and (v) inconsistent and/or dimensionality. It has also been noted by a number of authors that the criteria for IGD assessment tools are theoretically based on a variety of different potentially problematic activities including substance use disorders, pathological gambling, and/or other behavioral addiction criteria. There are also issues surrounding the settings in which diagnostic screens are used as those used in clinical practice settings may require a different emphasis that those used in epidemiological, experimental and neurobiological research settings.

Video gaming that is problematic, pathological and/or addictive (i.e., IGD) lacks a widely accepted definition. In a recent book chapter (in the 2014 book Behavioral Addictions: Criteria, Evidence and Treatment edited by Dr. Ken Rosenberg and Dr. Laura Feder), I and some of my Hungarian colleagues argued that some researchers consider video games as the starting point for examining the characteristics of this specific disorder, while others consider the internet as the main platform that unites different addictive internet activities, including online games. Recent studies have made an effort to integrate both approaches Consequently, IGD can either be viewed as a specific type of video game addiction, or as a variant of internet addiction, or as an independent diagnosis.

As I argued in one of my previous blogs, although all addictions have particular and idiosyncratic characteristics, they share more commonalities than differences (i.e., salience, mood modification, tolerance, withdrawal symptoms, conflict, and relapse), and this likely reflects a common etiology of addictive behavior. Consequently, online game addiction may be viewed as a specific type of video game addiction. Similarly, Dr. G. Porter and colleagues in a 2010 issue of the Australian and New Zealand Journal of Psychiatry, do not differentiate between problematic video game use and problematic online game use. They conceptualized problematic video game use as excessive use of one or more video games resulting in a preoccupation with and a loss of control over playing video games, and various negative psychosocial and/or physical consequences. However, unlike my conceptualization of gaming addiction, their criteria for problematic video game use does not include other features usually associated with dependence or addiction, (e.g., tolerance, physical symptoms of withdrawal), as they say there is no clear evidence that problematic gaming is associated with such phenomena. Researchers such as Dr. Kimberley Young view online gaming addiction as a sub-type of internet addiction and that the internet itself provides situation-specific characteristics that facilitate gaming becoming problematic and/or addictive.

In a 2010 issue of Computers in Human Behavior, Dr. M.G. Kim and Dr. J. Kim’s [11] proposed a Problematic Online Game Use (POGU) model that takes a more integrative approach and claims that neither of the approaches outlined above adequately capture the unique features of online games such as Massively Multiplayer Online Role Playing Games (MMORPGs). They argue that the internet is just one channel where people may access the content they want (e.g., gambling, shopping, sex, etc.) and that such users may become addicted to the particular content rather than the channel itself. This is analogous to the argument that I made over 15 years ago in a number of different papers that there is a fundamental difference between addiction to the internet, and addictions on the internet. However, MMORPGs differ from traditional stand-alone video games as there are social and/or role-playing dimension that allow interaction with other gamers.

The POGU model resulted in five underlying dimensions of addictive gameplay (i.e., euphoria, health problems, conflict, failure of self-control, and preference of virtual relationship). I also support the integrative approach and stress the need to include all types of online games in addiction models in order to make comparisons between genres and gamer populations possible (such as those who play online Real-Time Strategy (RTS) games and online First Person Shooter (FPS) games in addition to the widely researched MMORPG players). The POGU model comprises six dimensions (i.e., preoccupation, overuse, immersion, social isolation, interpersonal conflicts, and withdrawal).

Irrespective of approach or model, the components and dimensions that comprise online gaming addiction outlined above are very similar to the IGD criteria in Section 3 of the DSM-5. For instance, my six addiction components directly map onto the nine proposed criteria for IGD (of which five or more need to be endorsed and resulting in clinically significant impairment). More specifically: (1) preoccupation with internet games [salience]; (2) withdrawal symptoms when internet gaming is taken away [withdrawal]; (3) the need to spend increasing amounts of time engaged in internet gaming [tolerance], (4) unsuccessful attempts to control participation in internet gaming [relapse/loss of control]; (5) loss of interest in hobbies and entertainment as a result of, and with the exception of, internet gaming [conflict]; (6) continued excessive use of internet games despite knowledge of psychosocial problems [conflict]; (7) deception of family members, therapists, or others regarding the amount of internet gaming [conflict]; (8) use of the internet gaming to escape or relieve a negative mood [mood modification]; and (9) loss of a significant relationship, job, or educational or career opportunity because of participation in internet games [conflict].

The fact that IGD was included in Section 3 of the DSM-5 appears to have been well received by researchers and clinicians in the gaming addiction field (and by those individuals that have sought treatment for such disorders and had their experiences psychiatrically validated and feel less stigmatized). However, for IGD to be included in the section on ‘Substance-Related and Addictive Disorders’ along with ‘Gambling Disorder’, the gaming addiction field must unite and start using the same assessment measures so that comparisons can be made across different demographic groups and different cultures.

For epidemiological purposes, Dr. B. Koronczai and colleagues in a 2011 issue of Cyberpsychology, Behavior and Social Networking, asserted that the most appropriate measures in assessing problematic online use (including internet gaming) should meet six requirements. Such an instrument should have: (i) brevity (to make surveys as short as possible and help overcome question fatigue); (ii) comprehensiveness (to examine all core aspects of IGD as possible); (iii) reliability and validity across age groups (e.g., adolescents vs. adults); (iv) reliability and validity across data collection methods (e.g., online, face-to-face interview, paper-and-pencil); (v) cross-cultural reliability and validity; and (vi) clinical validation. It was also noted that an ideal assessment instrument should serve as the basis for defining adequate cut-off scores in terms of both specificity and sensitivity. To fulfill all these requirements, future research should adjust the currently used assessment tools to the newly accepted DSM-5 criteria and take much more efforts to reach and study clinical samples, which is an unequivocal shortcoming of both internet and gaming research.

In addition to further epidemiological and clinical research, further research is also needed on the neurobiology of IGD. A systematic review of 18 neuroimaging studies examining internet addiction and IGD by Dr. Daria Kuss and Griffiths in a 2012 issue of Brain Sciences noted that:

“These studies provide compelling evidence for the similarities between different types of addictions, notably substance-related addictions and Internet and gaming addiction, on a variety of levels. On the molecular level, Internet addiction is characterized by an overall reward deficiency that entails decreased dopaminergic activity. On the level of neural circuitry, Internet and gaming addiction lead to neuroadaptation and structural changes that occur as a consequence of prolonged increased activity in brain areas associated with addiction. On a behavioral level, Internet and gaming addicts appear to be constricted with regards to their cognitive functioning in various domains” (p.347).

The good news is that research in the gaming addiction field does appear to be reaching an emerging consensus. We noted in our 2013 Clinical Psychology Review paper that across many different studies, IGD is commonly defined by (a) withdrawal, (b) loss of control, and (c) conflict. However, it is critical that a unified approach to assessment of IGD is urgently needed as this is the only way that there will be a strong empirical basis for IGD to be included in the next DSM.

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About drmarkgriffiths

Professor MARK GRIFFITHS, BSc, PhD, CPsychol, PGDipHE, FBPsS, FRSA, AcSS. Dr. Mark Griffiths is a Chartered Psychologist and Professor of Gambling Studies at the Nottingham Trent University, and Director of the International Gaming Research Unit. He is internationally known for his work into gambling and gaming addictions and has won many awards including the American 1994 John Rosecrance Research Prize for “outstanding scholarly contributions to the field of gambling research”, the 1998 European CELEJ Prize for best paper on gambling, the 2003 Canadian International Excellence Award for “outstanding contributions to the prevention of problem gambling and the practice of responsible gambling” and a North American 2006 Lifetime Achievement Award For Contributions To The Field Of Youth Gambling “in recognition of his dedication, leadership, and pioneering contributions to the field of youth gambling”. His most recent award is the 2013 Lifetime Research Award from the US National Council on Problem Gambling. He has published over 500 research papers, four books, over 120 book chapters, and over 1000 other articles. He has served on numerous national and international committees (e.g. BPS Council, BPS Social Psychology Section, Society for the Study of Gambling, Gamblers Anonymous General Services Board, National Council on Gambling etc.) and is a former National Chair of Gamcare. He also does a lot of freelance journalism and has appeared on over 2000 radio and television programmes since 1988. In 2004 he was awarded the Joseph Lister Prize for Social Sciences by the British Association for the Advancement of Science for being one of the UK’s “outstanding scientific communicators”. His awards also include the 2006 Excellence in the Teaching of Psychology Award by the British Psychological Society and the British Psychological Society Fellowship Award for “exceptional contributions to psychology”.